陳弘森 副教授 高雄醫學大學 牙醫學系 tel: 07-3121101 轉 7008, 7020 e-mail:...

陳弘森 副教授高雄醫學大學 牙醫學系

TEL: 07-3121101 轉 7008, 7020E-mail: hosech@kmu.edu.tw

飲水氟化(Water Fluoridation)

學習目標氟化飲水的起源氟化飲水與牙科公衛台灣飲水氟化的歷史飲水氟化與口腔健康

學習資源：Murray JJ: Appropriate use of fluoride for human

health. WHO, Geneva, 1996

Systemic fluoridationIntroductionMechanism of action of fluorideHistory of Water fluoridationSystemic fluoride in dental public

healthRisk of systemic fluorideConclusion

Introduction

Fluorides in the environment

1. fluorides in soil 0.06-0.09% of the earth

2. fluorides in water lakes, rivers, artesian well.

3. fluorides in air from the dusts, burning of coal fires, volcanic activity

圖

Mechanism of action of fluoride

Table 5FACTORS OF IMPORTANCE FOR

CARIES-PREVENTIVE EFFECT OF F

• Systemic F supply during period of enamel mineralization and maturation

• F contact with erupted tooth surface (and plaque)

• High frequency of local F application

• Long duration of F contact with enamel surface

• F contact with newly-erupted tooth surface

• Protection against rapid leaching of F taken up by enamel surface

• Chemical conditions favoring F-apatite formation

SystemicDrinking waterTablet saltMilkTabletsDrops

Topic

• Toothpaste

• Mouth rinses

• Painting solution

• Varnishes

• Sucking tablets

• Chewing gum

History of Water fluoridation

History of dental fluorosis(I)

1888 Kuhns discovers in Mexico

1901 Eager discover in Naples (Italy)

1916 Mackay & Black discover in Colorado (USA)

1930 Kempf & Mckay discover in Arkansas (USA)

History of dental fluorosis(II)

1930 Churchill 12ppm [F-] in water

1931 Smith et al. Fluoride/dental fluorosis

1934 Dean Dental fluorosis classification

1939 Dean 1ppm for fluoridated

TABLE 21 Conversion table for form of fluoride

SOLUTION CONCENTRATION

Fluoride (F)(ppm) or (mg/L)

Fluoride(umol/L)

Sodium Fluoride (NaF)

(ppm) or (mg/L)

0.019 1.0 0.042

0.038 2.0 0.084

0.5 26.3 1.10

1.0 52.6 2.21

10.0 526.3 22.1

100.0 5250.0 220.9

250.0 13160.0 552.7

1000.0 52630.0 2209.2

scientific controls:

Fluoridation Control City

Grand Rapids, Michigan(January,1945)

Muskegon, Michigan

Newburgh, New York(May, 1945)

Kingston, New York

Brantford, Ontario(June, 1945)

Sarnia, Ontario

Evanston, Illinois(February, 1947)

Oak park, Illinois

TABLE 1-7 WORLD-WIDE WATER FLUORIDATION

Country

YearFirst

Adjusted

PopulationServed by

Fluoridated Water

Percentage of Total Population Served by

Fluoridated Water

Switzerland 1972 220,000 3

Syria (Natural F) 1,000,000 10

Taiwan 1972 40,000 0.2

Thailand (Natural F) 5,000,000 10

UK 1955 5,500,000 10

USA 1945 123,000,000 53

USSR 1960 30,000,00 11

Venezuela 1952 4,562,800 25

Yugoslavia (Natural F) 3,000,000 13

Systemic fluoride in dental public health

1. Mean def in Grand Rapids and Muskegon, 1951 (Arnold et al.)

Age

Grand Rapids Muskegon

No. of children

Mean def

No. of children

Mean def

4 168 2.13 63 4.46

5 853 2.27 351 5.25

6 750 2.98 294 5.67

Table 4. Comparing proportion of caries-free children in fluoridated and non-fluoridated areas15

Age(years) Fluoride % of children with no

caries

No Fluoride % of children with

no caries

6 89.3 79.8

7 66.8 49.7

8 49.4 27.5

9 33.1 14.5

10 26.6 5.7

Table Change In Caries Experience In Some Developed Countries

CountryTime

IntervalAge Group Caries

IndexCaries Experience Percent

ChangeStart End

Australia 1954-80 12 DMFT 7.2 2.5 -65

Denmark 1973-80 15 DMFS 15.9 10.8 -32

England 1971-81 12 DMFS 9.3 4.3 -53

Ireland 1961-79 13-14 DMFT 8.0 4.4 -45

Netherlands 1966-80 12 DMFT 8.2 5.5 -33

New Zealand 1973-78 8-9 DMFT 3.3 2.0 -39

Norway 1955-79 15 DMFT 16.5 10.8 -35

Scotland 1970-80 12 DMFT 8.1 5.8 -28

Sweden 1973-78 15 DFS 27.7 13.7 -51

TABLE 16 Mean scores for decayed, missing, or filled surfaces by age and quartile of socioeconomic status (Bell et al. 1982)

Ages in Years

6 8 10 12

Non-fluoridated

Lowest 25% 0.68 3.30 5.39 9.47

Next to Lowest 25% 0.55 2.67 4.90 8.47

Next to highest 25% 0.52 2.46 4.16 7.23

Highest 25% 0.43 2.09 3.22 6.70

Fluoridated

Lowest 25% 0.52 2.28 3.44 5.71

Next to Lowest 25% 0.49 1.92 3.74 4.97

Next to highest 25% 0.44 1.86 3.27 5.04

Highest 25% 0.39 1.89 2.87 4.91

1967 Backer Dirks fluorides

45% pit & fissure

60% proximal surfaces

75% free smooth surfaces

DMF decrease 50% index

The fluoride intake from water will depend on :

1. the fluoride concentration of the water,

2. the age of the person,

3. climatic conditions,

4. dietary habits.

Water Fluoridation in Taiwan

1971 – Dec. Kaohsiung City (0.5 ppm)

1972 – May Chung-Hsing New Village (0.6 ppm )

1986 – Oct. Discontinue

Evaluation of the effect of 12 year’s water fluoridation

1975

1978

1981

1984

中興新村 草屯原飲用水中含氟量 0.07 ppm 0.08 ppm

添加氟化鈉後含氟量 0.6 ppm 未添加乳齒齲齒 減少 40% 增加 19% (3歲

組 )

恆牙齲齒 前者較草屯減少 66%

(12歲組 )

The experience of using fluoride in Taiwan

1971/Dec – 1972/Dec Kaohsiung City/0.5 ppm1972/May – 1986/Oct Chung-Hsing New

Village (0.6 ppm)1992/July – 1997/June School mouth-rinsing program1993 Fluoride tooth-brushing (tooth paste)1994 Encourage using fluoride by DOH

Water fluoridationPowder type Sod. fluoride (NaF) Sod. fluorosilicate (Na2SiF6)

Liquid type Fluosilicic acid (H2SiF6)

School water fluoridation programs

1. by age 6

2. caries incidence

Supplemental fluoride therapy ：

prenatal fluoride therapy

postnatal fluoride therapy

劑量建議(參照美國兒童牙科醫學會 AAPD之氟攝取建議量 )

年齡 每日劑量

6 個月 ~3 歲 0.25 mg (= 小哈氟 ® 1/4mg 一錠 )

3~6 歲 0.5 mg (= 小哈氟 ® 1/4mg 二錠 )

6~16 歲 1 mg (= 小哈氟 ® 1mg 一錠 )

* 每晚睡前含著即可。

Effectiveness of Various Modes of Administering Fluorides in Improving Dental Health

Mode Concentration of Dose % Reduction in Dental Caries

Remarks

Community water fluoridation 1 ppm (1 mg/liter)* 55-70 Continues into adult life

School water fluoridation 4.5 ppm (4.5 mg/liter)* About 40 Only for school age children

Topical application 2% NaF solution 8% stannous fluoride1.2% acidulated phosphate fluoride, or gel

30-40 For children of all ages

Mouth rinse: Home or school rinsing daily Supervised school rinsing weekly

0.05% NaF0.2% NaF

20-50 Probably more effective under supervision

Tablets 2.2 mg NaF↑ 20-40 Effective in supervised school distribution: chew, swish, and swallow

Drops 2-2.2 mg NaF total of 4-12 drops

Probably same as tablets

Latitude in partial doses

Dentrifices 0.4% stannous fluoride, 0.22 % NaF, 0.76% Na monofluorophosphate

15-30 Adults and children: may be used in fluoridated areas

* Dosage in a temperate climate.↑ No vitamin fluoride mixtures have been accepted by the ADA Council on Dental Therapeutics because they lack flexibility in altering fluoride dosage.

Risk of systemic fluoride

Skeletal fluorosisDental fluorosis

Prevalence and severity of fluorosis

1. Amount, concentration, duration of fluoride

2. Stage of tooth development

3. Individual variations

4. Certain environmental variables

Table 4-4 Dean’s dental fluorsis classification

Category Dental fluorosis score

Description of enamel

Normal 0.0 Smooth, glossy, pale cream-white translucent surface

Questionable 0.5 A few white flecks or white spots

Very mild 1.0 Small opaque, paper-white areas covering less than 25% of the tooth surface

Mild 2.0 Opaque white areas covering less than 50% of the tooth surface

Moderate 3.0 All tooth surfaces affected; brown stain; marked wear on biting surfaces

Severe 4.0 All tooth surfaces affected; brown stain; discrete or confluent pitting

Date from Dean34 Source: Leske, G.S.; Rpa, L.W.; and Leske. M.C. Dental Public Health (chap. 43). In Maxcy-Rosenau Public Health and Preventive Medicine 11th ed. J.M. Last. ed. , pp. 1423-68. New York: Appleton-Century-Crofts. 1980

Dental fluorosis

ED DE Cervical portion

ED DE (Buccal surface)

Dental Fluorosis

0-4 yrs 621 126

621 126

4-6 yrs 754 457

754 457

Over 6 yrs 8 8

8 8

History of dental fluorosis(Taiwan)

1952 黃茂卿 台南縣 卜茂源 台南縣、高雄縣、澎湖縣

1987 Akiniwa 台灣中部地區

Tainan County --- 仁德鄉 80% DF

Penghn County --- 白沙鄉 70% DF

Taichung County --- 龍井鄉 50% DF

Nantou County --- 中興新村 20% DF

Water fluoridation

Growth & development

Cancer death rate

Down’s syndrome

Mortality rate

TABLE 7 FLUORIDE-CANCER CORRELATION

Positive Correlation No or Negative Correlation

Yiamouyiannis and Burk ,1977 Hegen et al. 1954

Heasman and Martin, 1962

Kinlen, 1975

Hoover et al., 1976

Kuzma et al., 1977

Erickson, 1978

Rogot et al., 1978

Raman, 1978

Glattre and Wiese, 1979

Fluoride ingestion by man1. fluorides in solid food range from 2 -10

mg of F/kg2. fluorides in drinks

飲料名稱 樣本數 平均值 標準差 最小值 最大值咖啡類 9 0.09 0.04 0.04 0.15

果汁類 21 0.08 0.03 0.02 0.16

可樂汽水類 14 0.06 0.03 0.03 0.14

運動飲料、健康飲料類 9 0.06 0.04 0.02 0.14

鮮奶、牛奶、調味乳類 22 0.08 0.05 0.03 0.24

奶茶類 9 0.57 0.15 0.38 0.84

紅茶類 15 0.65 0.42 0.16 1.78

綠茶類 10 0.52 0.33 0.24 1.15

烏龍茶類 10 0.79 0.31 0.4 1.43

其他茶類 22 0.48 0.38 0.1 1.28

表 23 ：各類飲料氟含量 (ppm) 的情形

★ 必須礦物質與其缺乏症類別 缺乏時所引起的主要疾病

巨量礦物質

鈣 骨質疏鬆症磷 骨骼疾病鉀 肌肉無力症、心律不整

硫礦 毛髮、指甲的發育障礙鈉 肌肉痛、痙攣鎂 心臟疾病、失眠、糖尿病、老人癡呆症

微量礦物質

鐵 貧血、失眠鋅 掉髮、皮膚疾病、味覺障礙銅 貧血錳 骨骼病變碘 甲狀腺腫硒 心臟疾病、關節障礙、動脈疾病鉬 痛風 ( 尿酸代謝障礙 )

鈷 惡性貧血鉻 葡萄糖耐受異常

AntifluoridationPublic health aspectsEnvironment aspectsCaries prevention aspects

Conclusion

反對飲水氟化的理由氟非營養素或維他命。氟為老化因子。齲齒是缺乏鈣、鎂、磷。牙科公衛調查不確定。飲用水是食品，非藥水。添加物不得超過中毒量百分之一。

結論評量氟化飲水對人類健康的考量

Thank You For Your Listening!

Evaluating dental fluorosis

color

hypoplastic changes

Table II Recommended adjustment in optimal fluoride level according to air temperature of the community

Average annual maximumdaily

air temperature

Recommendedoptimal

fluoride level

℃ ℉ ppm

10.0-12.1 50.0-53.7 1.2

12.2-14.6 53.8-58.3 1.1

14.7-17.7 58.4-63.8 1.0

17.8-21.4 63.9-70.6 0.9

21.5-26.2 70.7-79.2 0.8

26.3-32.5 79.3-90.5 0.7

Table 58 Ratios of Observed to Expected Numbers of Cancers in Certain Organs in Areas with Different Levels of Fluoride in Water in Great Britain (Royal College of Physicions,1976)

Site of cancer High F(1 ppm)

High-medium F (0.5-0.99 ppm)

Low F (0.2 ppm)

Very low F (0.1 ppm)

Thyroid 1.05 (45)* 0.79 (54) 1.27 (57) 1.02 (84)

Kidney 1.01 (129) 1.00 (198) 1.02 (131) 0.98 (233)

Stomach 0.88 (375) 1.15 (733) 0.90 (327) 1.05 (815)

Oesophagus 0.87 (73) 1.02 (131) 0.87 (73) 1.13 (177)

Colon 0.96 (386) 1.03 (618) 0.99 (385) 1.00 (719)

Rectum 0.93 (273) 1.11 (486) 0.94 (264) 0.99 (519)

Bladder 1.00 (430) 0.96 (632) 1.06 (444) 1.00 (786)

Bone 1.00 (18) 1.06 (30) 1.02 (19) 0.94 (31)

Breast 0.92 (567) 1.06 (999) 1.08 (650) 0.97 (1105)

TotalPopulation 482 398 779 054 510 045 896 625

*The total numbers of cancers observed are given in parentheses

Table 3 Supplemental Fluoride Dosage Schedule (mg/day*)

AgeConcentration of fluoride in drinking water (ppm)

<0.3 0.3-0.7 >0.7

2 weeks-2 years 0.25 0 0

2-3 years 0.50 0.25 0

3-16 years 1.00 0.50 0From American Academy of Pediatrics Committee on Nutrition : Fluoride Supplementation: Revised dosage schedule, Pediatrics 1979; 63:150. *2.2 mg sodium fluoride contains 1 mg fluoride

Antifluoridationist strategies1. not effective

2. harmful

3. no choice

Defluoridation of water

Additive methods

Adsorptive methods

Additive methods:

Calcium oxide (lime)

Magnesium compounds (dolomite)

Aluminum sulfate (alum)